Supporting the frail elderly

A #communitynurse for 13 years, Zhang Jin has attended to patients in unusual places, including HDB void decks and stairways, as #patients sometimes request for care to be done outside their homes. This is par for the course for the native of Shanxi, northwestern China, who came to Singapore 20 years ago to be a nurse.

“In a hospital setting, you have access to the necessary resources. As a community nurse, you work independently and must be resourceful and think on your feet," she shared.

Visiting different homes has enabled her to manage people from different backgrounds. This has been useful in her current role as #Nurse #Clinician ( Sengkang General Hospital ) of Ageing Successfully in Place – Independent Rewarding Lives (ASPIRE), a community-based #geriatric intervention pilot project, where she attends to patients aged 65 and above who are frail and require follow-ups by geriatricians. Patients who meet the above criteria are recruited for the programme at partnering clinics (General Practitioners or Polyclinics).

Zhang Jin then performs a comprehensive geriatric assessment of the patients’ functionality, fall risk, incontinence and nutrition status, and psychosocial needs. For ASPIRE, Zhang Jin is part of a multidisciplinary team comprising doctors, physiotherapists, occupational therapists, social workers, dietitians and community partners. Depending on the outcome of the patient’s assessment, she then refers the patient to the subject matter expert in the team for follow-up. Cognitive impaired patients, for example, are placed under the care of a geriatrician for further investigation, while those suffering from malnutrition will be referred to a dietitian.

Most people think that frailty is a normal part of ageing, but this is not so, stressed Zhang Jin. There are multiple contributing reasons that can be prevented with early interventions. She and her colleagues have attended to more than 270 patients since the programme began three years ago.

ASPIRE has been well-received. A daughter who accompanied her mother for the programme was so impressed that she referred her father to it. Another elderly couple who were due to be discharged from their physiotherapy sessions were keen to continue as the scheme is subsidised, with the first session being free and subsequent ones costing $10 each. However, to continue the rehab session, they had to be referred to a community partner, as patients are only allowed to be on the programme for a year.

According to Zhang Jin, her work as a community nurse has helped her grow professionally and personally. “Through regular case discussions in a multidisciplinary team, I have been able to expand my knowledge on caring for patients with certain conditions. As a person, I have also grown to be a lot more patient and appreciative of what I have,” she said.

This article was first published in Singapore Health Special Nursing Issue 2023.